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ANNUAL REPORT OF � � �, � � �
GUA►RDI.AN �F THE PERSON � � m 4' �"` �'
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COURT OF COMMQN PLEAS OF -
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CUI�-113�1Q�� COI;fNTY,PENNSYLVANIA� �
ORPHANS' COURT DIVISION
Estate of___ ���1� �� �E/SS L� , an Incapacitated Person
No. �Z/-/d-/p/yL
�. nv�.anuc��o�v ,
�UZJ4l1l CAR�l6�}�� �✓�i�lll �1) /�S ,was appointed
�Plenary�Limited Guardian of the Person by Decree of 7�.5 �}. �LA C��,J.,
dated�D�5—aQ��Cl�i��. �c�Q�) � //-02 Q�o/�.��/�f��1DC� fi��1A�- �Uc��,
�A. This is the Annu�l Report for tlie period from /l— r 'a�0/02 ,
to O��7p A,t�'Z 3/ , a? (the"R�port Period"j;or
� B. Tlus is the Final Regort far the period from ,
to , (the"Report Period"),and is filed
for the following reason:
1. The death of the Incapacitated Person. �ate of dea#h:
2. The Guardianship was ternunated by the Court by Decree of
J.,dated
For a Final Report,omit Sections II through I1-; °
Fornr G-03 rev.IQ.13.�6 Page'1 of 4
Es�ate of__ ��i�1� �, ,�E/SSL� ,an Incapacitated Person
II. PERSONAL DATA
Age of the Incapacitated Person:�' Date ofBirth: ,�-�/7-o?�
III. LIVING ARItANGEMENTS
A. Current address of the Incapacitated Person:
Of���/�o��
S�o �10��f�4� �R�U�
C.�Q r4��'�2R y Tc,�7', j'f�" /�v D �n Co
B. The Incapacitated Person's residence is:
Q own home/apartment
�nursing home
.�,
[�boarding home/personal care home
�Guardian's hame/apartment
�hospital ox medical facility
�relative's home(name,relationship and address)
�'t
other: ��M c�/i y C1q�E �'�-�L I Tt{
C. The Incapacitated Person has been in the present residence since �- �' �/02
. If the Incapacitated Person has moved within the
past year,state prior residence and reason(s}for move: �
Forn�G-03 re}.10.13.06 Page 2 of 4
Estate of J�i� �. ���S S L�7Z. ,an Incapacitated Person
D. Name and address of the Incapacitated Person's primary caregiver:
OA=K6r�oUC
So o �S��1`-1�rl �r4�v E
C�� �3�12V�y 1'�t'•, 'T'� I Co 0 t.�c�
rv. MEnTe�r.,nvFO�iT�oN
A. The major medical or mental problems of the Incapacitated Person are as follows.
CI�I D s�'T�4C�E p�M�tv�r-i f�
B. Specify what,if any,social,medical,psychological and suppori services the
Incapacitated Person is receiving:
N o�2 M�L. l���c��- C►���— �- -��y--1-n- ��-y S o ct ,�-t_
1�}C'T'1 U�'T7'L'�S
V. GUARDIAN'S C)PINIQN
A. It is the opinion of the Guardian of the Person that the guardianship should:
�continue
�be modified
�be terminated
Form G Q3 rev.IQ.13.06 Page 3 of 4
Estate of J�,� .3. .1��)SS1,t=72 , ,an Incapaci�ated Person
The reasons for the foregoing opinion are:
�' C N-�}S ��=� ��fl���oS� �}-S N�R-� ��� ��uv s���
� r�F �t�� �A19�l��-D}�4 CA+2� �D
��1�1�t-�r9- �n�i� t�
su�v�s�o� �
B. During the past year,#he Guardian of the Person has visited the Incapacitated Persan
�� times with the average visit lasfiing hours, 3a minutes.
�
77�e report of a social service organization emplQyed by the Guardian#o oversee and
eoordinate the care of the Incapacitated Person for the period eoiaered by this�eport may be
attached tv supplement this Report.
I verify thai the foregoing inforrnarion is correct to th��est of my knowledge,
information and belief;and that this Verification is subject to the penalties of 18 Pa.C.S.A. §4904
r�lative to unsworn falsification to authorities. -
�
/l-.S-/.3 �
Uate Signature p dian of the Person �
�S'�/z.�� �._..�,��',� ,�� T
Name af Guardian vf the Person(rype or print}
Or/70Z /C�O� �,.�� �0 S �A�lU��
Address
�i 33�.'3 t1�4 6�,1 �/} /So�3�
Clty,State,Zip '
�/� - 3LP lo - l�/�
Telephone
Form G-03 rev.i0.13.06 P8g6 4 Of 4
►
Estate of �155��/� , an Incapacitated Person
The reasans for the foregoing opuuon are:
B. I?uring the past year,the�uardian of the Person has visited the Incapacitated Person
� times with the average visit Iasting hours, �� minutes.
The report of a sociat service organization employed by the Guardian to oversee and
covrdinate the care of the Ineapacitated Person for the period covered by this Report may be
attached to supplement this Report.
I verify that the foregoing informarion is correct to the best of my knowledge,
information and belief;and that this Verification is subject to the penalties of 18 Pa.C.S.A, §49U4
relative to unsworn falsification to autharities.
// -/����
Date Si e of Gu ian of the Person
� �� d��
Name of Guardian of the Person(type or printj
�� ��l /� ��Q rU�( �J����
Address
�r���s��r �� /���1
Ciry.State.Zip
��� ��9����
Telephane
Form G-03 re►�.10.13.06 Page 4 of 4